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Case HistoryEditWhile Dr. House is at an off-track gambling parlor, the person in front of him is trying to place a bet but doesn’t know how. As there are only 30 seconds left to bet, a woman comes in and tells the betting clerk that the customer wants a two dollar exacta box, two, four, six, three and tells the guy to give him twenty four dollars. She winks at House, who puts a five-hundred dollar bet on the three horse. Anica tells him that he might as well burn his money. Anica tries bets on the same race as Dr. House; Termigator to win. However, the window closes before she can place her bet. Anica tells Dr. House that her horse was fourteen-to-one. House tells her that the slow bettor saved her money. While Dr. House is watching the race, Anica collapses from a seizure. Dr. House asks if anyone is a doctor. Someone starts giving Anica CPR, they tell House that they took a CPR class at the YMCA. House tells him that, that would be useful if she was having a heart attack instead of a seizure. The guy asks if he should hold her tongue down. House tells him to call an ambulance. House notices strange bruising on her. Interested, he tells the guy to tell the paramedics to bring her to Princeton-Plainsboro. Since he wants the case, he tells the guy to tell the paramedics that her doctor’s name is House. Ironically Termigator wins the race by two lengths. Dr. Foreman examines Anica on admission notes that her platelets are at 89 - she's anemic and she has a blood alcohol level of 0.13. Dr. Chase thinks she might be a prostitute that it's an STD . Dr. House tells him that Anica has no fever. Foreman says that alcohol abuse explains it all, it causes seizures and affects her bloods ability to clot which causes bruising. He tells them to start her on heparin and she'll be fine by the morning. Dr. House tells him that the bruises are not petechial, which means that it's not DIC. Dr. Foreman thinks that the bruises may have been caused by trauma, she probably got beat up by her boyfriend. Dr. House thinks that Dr. Foreman is judging her without meeting her. Dr. Foreman says that she's a regular at off-track betting and he can't see her holding down a nine-to-five job and going to PTA meetings. House tells him that he was at OTB and he has a nine-to-three job. Dr. Cameron thinks it could be SLE, familial telangiectasia or even Cushing's. Dr. House wants them to scan for Cushing's, because it explains the seizure and the bruising. Dr. Foreman says it doesn’t explain the anemia. Dr. House thinks she may not eat a lot of meat, that could cause the anemia. Foreman says that DIC caused by alcohol abuse is far more likely, and tells Chase and Cameron to do a full workup, medical history and physical. He also tells them to get her an MRI and an LP. Dr. House asks if Dr. Foreman ever so subtly asked him to get the patients history. Dr. Foreman reminds him that Cuddy put him in charge the previous week. Dr. House goes to Dr. Cuddy to make it clear that he’s the attending on the case, but Dr. Cuddy backs Dr. Foreman and reminds Dr. House that for the rest of Dr. House’s supervision period, Dr. Foreman is the attending.
Anica is answering a questionnaire. One of the questions is: "Do you wear a seat belt?". Anica asks if that is even relevant to a seizure. Dr. House tells her to skip it, another one is: "Were you vaccinated for polio?". She thinks he gave her the form intended for Franklin Roosevelt. Another irrelevant question: "Are you generally satisfied with your life?". Anica asks what a respectable doctor was doing in an OTB parlor, but somehow that question doesn't seem relevant anymore. Dr. House asks what her excuse is, Anica tells him that it turns her on. Dr. House asks if she is on drugs, she says no. He asks if she likes casual sex or rough sex, he tells her he needs to know because he is a doctor. She tells him that she just moved there and hasn't had any sex, no job yet either. He asks if her bruises hurt. She says no. She denies being on prescription drugs, hormones or prednisone. He asks if she is a vegetarian, Anica says no enthusiastically. He tells her she might have something called Cushing's syndrome, but Anica already knows what Cushing's is. It means her pituitary is overproducing ACTH which is causing her adrenal glands to push to much cortisol in her bloodstream. Anica tells House that she had it last year, they did brain surgery and removed an adenoma from her pituitary gland.
They do an MRI, but they don't see any re-growth from the tumor, but Dr. House says it’s probably a micro-adenoma. Dr. Foreman asks Dr. House if Anica’s medical records have arrived, but they have not. Dr. Foreman tells Dr. House to go do the lumbar puncture.
Dr. House does the lumbar puncture and uses horse racing metaphors to make her more "comfortable". Dr. House appears to have trouble finding an entry point. Anica says her chest feels a little tight. Dr. Cameron offers to do it for Dr. House. Suddenly Anica’s blood pressure rises to 240 over 140. Dr. Cameron tells Dr. House to take the needle out. Dr. House tells the nurse Anica had a hypertensive crisis and orders intravenous lopressor drip with titrate to systolic.
Dr. House tells Dr. Foreman that it's Cushing's because Cushing's plus stress equals hypertensive crisis. He explains he deliberately did a clumsy LP to set off the crisis. However, Dr. Foreman still thinks that it's DIC and she had a hypertensive crisis because it's been at least six hours since her last drink. She's detoxing. Dr. Chase thinks that the Cushing's tumour could be on her lung or pancreas. Dr. Foreman agrees do allow a whole body scan for a tumor again. He also makes it clear that if it’s negative, they have to put her on a lithium drip and find a bed for her in a rehab clinic.cancer. Anica asks how something in her pancreas could cause her to have a seizure. Dr. Cameron tells her that on one-year survival rate for pancreatic cancer is less than 20%. Cameron tells her that they need to biopsy the mass to see what they're dealing with, and then they can recommend options from there. Anica says that it sounds good, she doesn't seem at all upset about the possible cancer. Cameron tells her she will need Anica's consent to the biopsy. She readily agrees to the biopsy. Cameron wishes Anica luck.
Dr. Cameron is talking to Dr. Wilson while doing the biopsy, she tells him about how Anica barely had any reaction. Wilson says he's had people hug him and people take a swing at him. Cameron says that it was more like she didn't hear her. Luckily, the biopsy for pancreatic cancer is negative. Dr. Chase thinks that the mass is just scar tissue. Dr. Foreman thinks that she isn't sick at all, other than being an alcoholic. Dr. House still thinks that she has Cushing's – her latest ACTH reading 65 picograms per milliliter - something set it off. Dr. House tells Chase to set her up for a venous sampling. Dr. Cameron says that there is another possibility; Anica didn't even read the consent form for the biopsy. Dr. Cameron thinks that maybe she didn't read it because she knew nothing was wrong with her. There is another explanation for the Cushing’s - she may have injected herself with the ACTH. Her behavior suggests Munchausen syndrome. She's had four hospitalizations in the last four months, and she's had no symptoms since she got to the hospital. The scarring on her pancreas could be caused from injecting herself with benzene to set off the seizures. But Dr. House argues that Anica has had brain surgery; you can fake a stomach ache but you can't fake a brain tumor. Dr. Cameron counters that you can fake an invisible one. Dr. Cameron thinks that they should break into her apartment to look for medication and syringes, but Dr. House says that a venous sampling is much easier. Foreman adds that it is more dangerous. He orders Dr. House and Dr. Cameron to break into Anica's house.
Dr. House and Dr. Cameron take House's motorcycle to Anica's house. They find books in the bathroom, House says either she's very smart or she has a severe fiber deficiency. Dr. Cameron finds out that she's got an appointment with her ophthalmologist on Tuesday and an appointment with her gynecologist on Thursday. She points out that multiple appointments with multiple doctors is a symptom of Munchausen's. Dr. House says that she has a vagina and trouble reading. She has three pairs of glasses each with different prescriptions, which would be explained by a tumor pressing on the optic nerve. Dr. Cameron thinks it's Munchausen's but Dr. House doesn't, but she has no proof to show Foreman. Dr. House counters that none of her other doctors found any mental illness issues.
Dr. Foreman tells Dr. House that Munchausen's patients are good at covering their tracks. Dr. Cameron tells him to look at the pathology reports from the surgery that she had in Chicago, they removed 30% of her pituitary and found no tumor. Dr. Foreman argues that it's possible that the surgeons just missed it, in that kind of surgery, it's just cutting and hoping. Dr. Foreman tells them to get Anica's consent do the venous sampling. Dr. House thinks that Dr. Foreman is just taking the safe route, not because he thinks that Dr. House is right.
Dr. Cameron asks for Anica's consent to do the venous sampling. Dr. Cameron tells her that she thinks that it's a completely unnecessary procedure. Dr. Cameron tells her she thinks she’s mentally ill and accuses her of injecting injected herself with ACTH to induce Cushing's to get attention from doctors but Anica denies it. Anica says that she wants another doctor, she doesn't want a bitch. Anica signs the consent forms.
Anica is being prepped for the venous sampling, but Dr. Foreman gets a call, Anica’s urine is turning orange. Dr. Cameron already knows for some reason and Dr. Foreman asks how she knew. Dr. Cameron says it's because that's what rifampicin does. Dr. Cameron says that if a Munchausen's patient thinks that she's about to get busted, and she sees pills labelled "dangerous, might cause seizures" she might grab a couple. And if that label were accidentally on a bottle of antibiotics, and if that bottle were accidentally left in her room, she might take them and her urine might turn orange. Dr. Foreman realizes that Dr. Cameron set her up. However, it's clearly Munchausen's. Anica did all of it to herself.Dr. House looks through Anica's medical records. Dr. Cameron is talking to Anica, whose tears are orange. Anica denies doing it to herself, she says that she had a seizure, she's sick and she needs their help. Dr. Cameron says she doesn't need help from that department, the half-life of rifampin is three hours. After that, she'll get her psych referral and her discharge papers. Anica once again denies doing it to herself and Cameron thinks she’s just being hostile when co-operation stops working. Dr. Cameron finally leaves. However, Dr. House tells Dr. Foreman that they can't discharge her because she's still sick. Dr. Foreman asks if he has another explanation for orange urine. Dr. House says that Munchausen's is correct but not complete. Dr. Foreman thinks that he just doesn't want to admit that Dr. Cameron skunked him. Dr. House says that at the end of The Boy Who Cried Wolf the wolf really does come and he eats the sheep, and the boy, and the parents. Dr. House tells them that he checked her records, all her hospitalizations were for different things. Brain tumor, fainting spells, skin rashes and seizures. She's had every blood test known to man and the results are all over the map. But there is only one constant, low HCT. The anemia's real. Dr. Cameron says that there are a million things she could have taken to have done that. House says it could just be her modus operandi. House thinks that she has aplastic anemia, which would mean without proper treatment she'll continue to get sicker, weaker and eventually she'll start bleeding internally and die. Chase says that if her bone marrow was dying, the entire blood panel would be affected, but her white count's normal. Dr. House thinks that it'll change. House wants to do a bone marrow biopsy, but Dr. Foreman refuses to do a biopsy he says that the more attention they give her, the more she'll want. Dr. House says that they can use blood left over from previous tests, but Dr. Cameron says that blood tests alone can't confirm aplastic anemia. Dr. House tells her that he knows and that's why he wants to do a bone marrow biopsy. But blood tests could show a systemic disease a virus or toxin could be the cause. Dr. Foreman says that he can test the blood but the patient is off limits. If the results are positive he can do the bone marrow biopsy. Dr. House tells the pathologist what to test Anica for, but she says that he'll need more blood. Dr. House tells her that he can't get any. She says that she can't do it. Dr. House eventually convinces her to try.
Dr. House comes back with test results that show Anica's Epstein-Barr titers are through the roof. It’s the most common cause of aplastic anemia. However, Dr. Foreman notes that the fetal hemoglobin is also elevated. The only condition that causes that is sickle-cell anemia, and none of the other blood tests indicated that. Dr. Foreman figures out that he didn't use Anica's blood. Dr. House finally admits he didn’t have enough blood to complete the tests, but Dr. Foreman refuses the biopsy and alerts the nurses to keep Dr. House away from Anica. Dr. House tries to convince Dr. Chase to get the bone marrow biopsy, but he refuses at first because he agrees with Dr. Foreman and Dr. House will continue to treat him badly when he’s back in charge. However, he finally agrees to try. However, when he orders a stroke cart in Anica’s name, the nurses alert Dr. Foreman and he stops the procedure. Dr. Cuddy tells Dr. House that she processed Anica's discharge papers, she's on her way out.
Anica is getting into a taxi when Dr. House stops her. He asks Anica if she wants another medical test and tells her to sit down. He asks her if she knows what colchicine is, Anica says no. Dr. House tells her that it's for gout, and it would decimate her white blood cells, and leaves almost no trace. It’s great for faking your way into hospitals. She denies faking, but Dr. House tells her to shut up. Dr. House asks if she had a close relative, like a sister, who was sick, and when she saw all the attention she got while Anica was left alone, ignored. He figures that’s what caused her Munchausen's. She denies it again but Dr. House tells her to stop denying it. Dr. House tells her that he can save her life because she has aplastic anemia. House tells her it means that she's not just mentally ill. House tells her it makes the rest of her appear well so he's got to make it seem as sick as she’s supposed to be by injecting her with a drug that simulates the symptoms that she already has. He tells her that she's hit the Munchausen's jackpot. He's going to give her insulin to induce a seizure and colchicine to kill her white count. That will “confirm” his diagnosis of aplastic anemia. However, if she faked the anemia, the drugs will probably kill her. She says she hasn’t taken anything else except what he’s already guessed she’s taken. Dr. House injects her. Anica admits to Dr. House that her mother had multiple sclerosis and was in and out of hospitals all the time. People were always trying to do things for her - ring her food, brush her hair or make her happy. Her mother died when Anica was 16. Dr. House leaves telling Anica that he can't be around when her symptoms restart because it would look suspicious, but he assures her that people walk by all the time and someone will find her. She has a seizure from the insulin, but a passerby sees her soon after and alerts the hospital staff.Anica is readmitted, but Dr. Chase and Dr. Foreman thinks that she faked another seizure. Dr. Foreman says that once she's stable they need to get her out of there for good. However, Dr. Cameron comes in and says that they can't because her white count is down. Dr. Foreman also finds her hematocrit and platelets are off and realizes that her bone marrow is shutting down - she actually has aplastic anemia. Dr. Cameron thinks that none of the other blood tests indicate it, but Dr. House says that tests aren’t always perfect. Dr. Foreman admits that Dr. House was right. He goes to tell Anica. Anica asks Dr. Foreman who he is, and he tells her that he is in charge of her case. He tells that her bone marrow can’t make blood anymore and that the anemia has been developing for months. She asks if it’s only the latest white blood cell count that is leading him to this conclusion, but he says that her previous test results point in the same direction. He tells her that a bone marrow transplant could cure her, but she realizes it could be fatal as well. He tells her that the other option is weekly blood transfusions for the rest of her life. Anica tells Foreman that she just wants to be healthy. Anica agrees that it isn't that much fun when you’re actually sick. He tells her that they'll check for a donor. Anica says thank you.
Before doing the operation Dr. Wilson tells her that they need to kill all the old marrow with radiation therapy first, keeping her in a sterile room for two weeks while they ensure the old marrow has died. Then they will give her the donor marrow and keep her in the sterile room for two more weeks until the bone marrow is working again. They start the radiation treatment while Anica asks for Dr. House.
Meanwhile, Dr. House is lying on Anica's hospital bed. He sniffs her pillow, looks in one of her drawers, finds some of her clothes, and smells those as well. He goes to the radiation room tells the team to get Anica out and turn the machine off. He asks how long she's been in there, and Dr. Wilson tells him three minutes. He tells them that she doesn't have aplastic anemia, she has an infection. Dr. Cameron says that her white count would be through the roof, hers is on the floor and she has no fever. Dr. House explains that her self-inflicted Cushing's suppressed her immune system, stopped her from having a fever and hid the infection. Clostridium perfingens would explain the other symptoms. Dr. Chase points out it wouldn’t explain the crashing white blood cell count. Dr. House tries to explain that trying augmentin is safer than radiation therapy. Dr. Foreman is amazed that Dr. House wants to try something safe and asks what’s going on. Dr. House finally suggests she injected herself with colchicines, but Dr. Foreman realizes that would be too much of a coincidence and accuses Dr. House of injecting her against her will, but he tells him he had consent. Dr. Foreman reminds him that Anica is mentally ill. Dr. House says that she would have gotten sicker when he said she was going to get sicker but when Dr. Cameron gave her refampin it suppressed the symptoms until she stopped taking it again. Dr. House tells Anica that she has a common bacteria, but that the bruises that she gave herself for the Cushing's made an excellent home for it. It then spread to her internal organs, causing her symptoms. Dr. Foreman agrees to augmentin.
Anica agreed to outpatient psychiatric treatment. However, she is seen at St. Sebastian’s Hospital, where the doctor there says that her white count is way down. They admit her to run a few more tests.